Provider Demographics
NPI:1265024103
Name:AVALON RANCH
Entity Type:Organization
Organization Name:AVALON RANCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:SUSAN
Authorized Official - Last Name:ROGGE-ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-302-8304
Mailing Address - Street 1:106 N MESQUITE ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-4960
Mailing Address - Country:US
Mailing Address - Phone:575-302-8304
Mailing Address - Fax:
Practice Address - Street 1:106 N MESQUITE ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-4960
Practice Address - Country:US
Practice Address - Phone:575-302-8304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility